Healthcare Ethics – Balancing Autonomy and Beneficence

Introduction

When patients seek healthcare, they and their families expect healthcare professionals to act within their best interests and treat them with dignity and respect while adhering to their profession’s rules, regulations, laws and ethical standards. Patients want healthcare professionals to treat them as individuals and involve them in making decisions to meet their own needs, preferences, beliefs and wishes regarding their care and treatments.

Ethics involves applying moral principles to healthcare, and ethical decision-making is critical in healthcare practice. Understanding how to navigate these principles is essential for those working in the sector. It often requires them to balance respect for patient autonomy with beneficence.

Getting the balance right between patient autonomy and beneficence can help healthcare professionals do what is best for their patients while allowing them to make informed decisions regarding their own healthcare. It ensures care is person-centred and holistic so patients get the care and treatments they need to improve their outcomes.

This blog post aims to provide insights into the ethical dilemmas surrounding autonomy and beneficence in healthcare. It will delve into the complex ethical considerations within healthcare, particularly the delicate balance between patient autonomy and the principle of beneficence (doing good).

Defining Autonomy and Beneficence

According to the British Medical Association (BMA), “autonomy is usually expressed as the right of competent adults to make informed decisions about their own medical care”. Autonomy also requires healthcare professionals not to influence a patient’s decision and requires their capacity, consent or an informed agreement before investigations and treatments occur.

Beneficence is “a core principle in medical ethics that guides practitioners to act as they believe is in the best interest of the patient” (The Medic Portal) and essentially means “do good”. The principle of beneficence requires healthcare professionals to balance treatment benefits against the risks and costs.

Respect for autonomy and beneficence are two of Beauchamp and Childress’ Four Principles, along with:

• Non-maleficence – healthcare professionals should avoid causing harm to patients; any harm associated with treatments should not be disproportionate to their benefits.
• Justice – healthcare professionals should treat patients in similar circumstances similarly and fairly distribute benefits, risks and costs.

These four principles form part of an ethical framework of healthcare issues to consider generally when making decisions about patients’ care. Healthcare professionals may find situations where patient autonomy and beneficence conflict, and they must balance them against one another. For example, a patient may not have the autonomy to make decisions due to a lack of mental capacity, so the healthcare professional has to decide what is in the patient’s best interest. Here, beneficence overrides patient autonomy.

Healthcare professionals have legal duties regarding healthcare ethics and have a duty of care to their patients. Further information on healthcare ethics and the law is here.

The Role of Informed Consent

The requirements of informed consent are regarded as a cornerstone of ethical medical practice and are ever-present in healthcare (Pugh, 2020). It is also an essential part of international human rights law.

Informed consent is a process where a healthcare professional provides sufficient and relevant information to a patient so that they understand the benefits, risks and alternatives of a given treatment or intervention. It also includes informing patients what happens if procedures do not go ahead.

Informed consent is important in respecting patient autonomy. Competent adults have the right to make informed decisions about their own medical care. However, they can only make these decisions if they have been given enough information by healthcare professionals and they have an opportunity to decide for themselves.

Consent must be valid, which requires it to be voluntary and informed, for example:

• The patient must have the capacity to understand the information given to them to make their own informed decisions and consent to treatment or the sharing of their information.
• The patient must be able to make decisions voluntarily, i.e. they must be free to decide and not be pressurised, influenced or persuaded by healthcare professionals or anyone else, i.e. family or friends.
• The patient must give their consent freely, and it should be obvious as to what they are consenting.
• The patient must be able to opt in rather than having to opt out. They must be able to refuse or withdraw consent at any time easily and without detriment.
• Patient’s informed consent and the decisions they make, e.g. treatment refusal, must be respected by healthcare professionals.

Ethical Dilemmas

Ethical dilemmas in healthcare are common and can occur when there are two or more conflicting ethical principles or values. Patient autonomy and beneficence often clash, as what is in the patient’s best interests may go against their wishes, beliefs or preferences, or they cannot make decisions themselves due to a lack of capacity.

Here are some real-world ethical dilemmas where patient autonomy and beneficence may conflict:

• A terminally ill child is on life-support and has sustained brain damage. Based on evidence, doctors opine that withdrawing life-support is in the ‘best interests’ of the child, as there is minimal chance of them regaining consciousness. If they do, they are likely to suffer from severe cognitive and physical disabilities. However, the child cannot decide as they are unconscious and would be too young anyway, and the parents disagree with the doctors.
• A mentally ill patient is in crisis and is threatening to harm themselves and others. Crisis intervention has been unsuccessful. It is now an emergency and a real risk to the patient and others. Mental health professionals break confidentiality to inform the police who detain (sections) the patient under the Mental Health Act 1983 for their ‘best interests’. The patient is detained and treated without their agreement for their safety and others.
• An older patient has dementia and a water infection (urinary tract infection), which has caused delirium. They are unable to communicate how they feel, but they need to get the correct treatments quickly, as infections can speed up the progression of dementia (Age UK). Because of the delirium, they cannot understand what is going on or the treatments they need. As they have no family, doctors consult an independent mental capacity advocate (IMCA) and make a decision to treat the patient as it is in their ‘best interests’.

Balancing ethical principles can be complex, as it requires assessing and analysing individual cases, carefully navigating them and thoughtful decision-making based on available evidence and information. Healthcare professionals must balance non-maleficence, justice, autonomy and beneficence, especially the latter principles, as they are all cornerstones in healthcare ethics.

Patient autonomy and beneficence are enshrined in law and human rights. They are a part of healthcare ethics, rules and standards, which healthcare professionals must follow to remain registered, to be on the right side of the law and to avoid negligence and injury claims. One of the most shocking cases of autonomy violation was when a surgeon branded his initials onto two patients’ livers during surgery and was struck off from the register.

Healthcare professionals can also find the balance challenging when they have to make decisions for patients and their families that go against their wishes, preferences and beliefs, which can be distressing, even though it is for the good of a patient.

Case Studies

Autonomy and beneficence are often in tension with each other in healthcare. Here are some case studies highlighting the ethical dilemmas those working in the sector can face and how healthcare professionals resolved them:

• Case Study Application of an Ethical Decision-Making Process for a Fragility Hip Fracture Patient (Haslam & DePaul, 2019) – balancing a lack of capacity with existing ill health and surgery risks. The 93-year-old patient will likely die if they do not have surgery, and if they do have the surgery, there is a risk they will not survive.
• Ethical dilemmas concerning autonomy when persons with dementia wish to live at home: a qualitative, hermeneutic study (Smebye, et al. 2016) – has various case studies on the ethical dilemmas when caring for people with dementia living in their own homes and balancing autonomy with their safety and well-being.
• The patient suicide attempt – An ethical dilemma case study (Jie, 2015) – balancing patient confidentiality, consent and autonomy with disclosing a suicide attempt to other healthcare professionals. The patient with end-stage aggressive prostate cancer told a nurse that he planned to commit suicide and asked the nurse not to tell anyone.
• A judge ruled that doctors could give a five-year-old girl from a family of Jehovah’s Witnesses a blood transfusion against her parents’ wishes (The Independent) – balancing religious beliefs with a life-saving procedure. The Leeds Teaching Hospitals NHS Trust made an application to the courts, as the girl had sickle cell disease, which was threatening her life due to her deteriorating condition. Her parent’s religious beliefs, as Jehovah’s Witnesses, would not allow them to consent to the blood transfusion.

The ethical considerations will differ between different cases. Healthcare professionals must navigate ethical dilemmas and can balance patient autonomy and beneficence by:

• Person-centred care – provides personalised and compassionate care and treatments that meet individual patient needs, wishes, beliefs and preferences.
• Shared decision-making – healthcare professionals and patients work together to respect patient’s autonomy and balance it with beneficence.
• Effective and open communication – healthcare professionals ensure that communication with patients is open and transparent so patients better understand and are well-informed.
• Robust healthcare policies and guidelines – every healthcare provider has policies on ethics specific to their sectors and clear guidelines for resolving ethical conflicts.
• Ethical training and education – healthcare professionals are given appropriate training on healthcare ethics and the policies, rules and guidelines relating to their sector.

Shared Decision-Making

Providing person-centred care that meets patient’s needs, beliefs and preferences requires collaboration between various healthcare professionals and patients. An essential aspect of this collaborative approach is shared decision-making (SDM).

According to NICE, “shared decision-making is a joint process in which a healthcare professional works together with a person to reach a decision about care”. It also ensures:

• Any tests, treatments and interventions selected are evidence-based and align with a patient’s needs, values, beliefs and preferences.
• Healthcare professionals share information with the patient and have open discussions with them so they understand any benefits, risks, potential consequences, alternatives and possible outcomes of treatments and interventions.
• The patient has appropriate and sufficient information to make informed decisions about their care and treatment that meets their needs.
• A patient has a choice as to how much they want to be involved in decision-making, i.e. some may prefer not to have an active role.
• Healthcare professionals support the patient in making decisions regarding their care and treatment.

Patients want to be more involved in making decisions about their own health and healthcare (NHS England), and it has many benefits, such as:

• Better relationships between patients and healthcare professionals.
• Meeting legal and ethical obligations.
• Ensuring adherence to professional codes of conduct and standards.
• An increase in patient involvement and engagement.
• Fewer patient regrets.
• Reduces unwarranted clinical variation
• More effective decision-making and improved health outcomes.
• A decrease in complaints and legal action.

SDM is crucial in respecting a patient’s autonomy, as it promotes their right to have a say and make informed decisions about their care and treatment without undue influence from healthcare professionals.

It does not mean that healthcare professionals or patients solely make decisions. SDM is a process where both make decisions; healthcare professionals have a role in educating their patients about care and treatments and supporting patients to align their choices with their values. Patients can choose their level of responsibility regarding final decisions, thus promoting their autonomy (Ubel, et al. 2018)

SDM also incorporates beneficence, as healthcare professionals balance treatment benefits against the risks and costs and do what is in the best interests of their patients, from diagnoses to treatment and beyond. Knowing what is best for patients requires understanding their preferences, values and beliefs, which healthcare professionals can gain from collaborating and SDM with their patients.

Legal and Ethical Frameworks

There are legal and ethical frameworks that guide healthcare decision-making, which those working in the sector must understand and comply with. One covered already is Beauchamp and Childress’ Four Principles, a widely used ethical framework for general healthcare issues (UKCEN).

The legal and ethical frameworks that will apply will depend on the type of healthcare setting in which healthcare professionals work and their UK country. Some examples include (this list is not exhaustive):

• The Health and Social Care Act 2012 – the NHS Commissioning Board and the clinical commissioning groups have duties to promote the involvement of patients and carers in decisions about their care and treatment and to enable patient choice (The Department of Health).
• The Mental Capacity Act 2005 – requires healthcare professionals to involve people who lack capacity in decisions about their care and treatment “so far as practicable”. They also have a legal duty to consider the Code of Practice when working with people who cannot make decisions for themselves. There is also a guide for health and social care workers.
• Montgomery v Lanarkshire Health Board (2015) – a landmark civil case for informed consent and the importance of shared decision-making. A key passage from the judgement is – “The doctor is therefore under a duty to take reasonable care to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments” (The MDU).

There are other civil cases with judgements relating to informed consent and capacity from the General Medical Council (GMC) here

Ethical decision-making is intrinsic in professional codes of conduct, standards and committees, and there are many examples such as (this list is not exhaustive):

• The National Institute for Health and Care Excellence (NICE) Guidelines – healthcare professionals must consider NICE guidelines when making decisions with patients.
• HCPC Standards of Conduct, Performance and Ethics – provide an ethical framework within which their registrants must work.
• NHS England Ethical Framework – sets out 15 ethical principles that must be adhered to by NHS England as a public body.
• NICE Critical Care Clinical Decision Frameworks – frameworks, tools and templates for clinicians to support them in decision-making.
• The British Medical Association (BMA) Ethics Guidance – advises UK doctors on the legal and ethical issues they may encounter in their professional clinical practice.
• The Medical Ethics Committee (MEC) – consists of members of the BMA who debate ethical issues on the relationship between the medical profession, the public and the state. Clinical ethical committees also have an essential role in helping healthcare professionals address ethical dilemmas (Williamson, et al. 2007).
• Advanced directives – these are also known as advanced decisions or living wills. They are legal documents that detail the medical treatments a person wants to refuse in the future and if they cannot make or communicate their own decisions. They are important, as patients can maintain autonomy and control over their medical treatment, and healthcare professionals can use them as a framework for decision-making. The Social Care Institute for Excellence has guidance and an example of a decision-making flowchart in a toolkit here.

NICE has a list of further professional guidelines, standards and laws that healthcare professionals should follow when making decisions here. They should also comply with those from their professional bodies and consider the frameworks described by UKCEN.

Legal and ethical frameworks provide a set of laws, standards, guidelines and principles that healthcare professionals must follow to ensure they operate legally, ethically, competently, and with integrity and respect. The frameworks standardise the decision-making process to ensure consistency across the sector, help look at ethical issues systematically and outline actions needed. However, they do not tell healthcare professionals what to do in each situation and do not solve ethical dilemmas on their own.

Healthcare professionals should use legal and ethical frameworks and their own judgment to analyse and evaluate potential choices and decide on a course of action with the most moral and balanced outcome. Frameworks can help navigate and resolve ethical dilemmas, as they give structure and clarity to the decision-making process and an avenue for healthcare professionals to justify their decisions, thus protecting both them and patients.

The Role of Ethics Committees

A clinical ethics committee is a multidisciplinary group of various health and social care professionals and may include community representatives (lay members). Membership of a committee is usually voluntary, and members will meet regularly.

The committee’s role is to help address ethical dilemmas when providing patient care and support healthcare professionals to make decisions. They may also:

• Discuss various ethical issues, such as consent, capacity, advanced directives, confidentiality, refusal of treatment, withholding/withdrawing treatment and do not resuscitate orders.
• Help interpret national guidelines.
• Contribute to NHS Trust and other health care institution policies and guidelines.
• Provide ethical training and education.
• Provide ethical support to clinicians and assist with moral distress.

The committee confidentially discusses and advises on ethical issues and provides an opportunity for a structured decision-making approach. However, they may need to seek advice from an ethicist or individual with training in the subject, especially in complex cases (UKCEN), and it is important to note that they do not make final clinical decisions and do not offer direct services to patients.

Committees should use ethical frameworks and tools to help them discuss and analyse ethical issues to ensure a clear and consistent process and deal with the ethical aspects of the decisions to be made by healthcare professionals. They should consider ethical principles in their discussions and evaluations.

Cultural and Religious Considerations

The UK is highly diverse, with people from different cultural, spiritual and religious beliefs, which can significantly influence patient experiences and treatment decisions. Each person will have varying needs, preferences and values relating to their beliefs and may address healthcare completely differently. According to the Office for Health Improvement and Disparities:

“Cultural, spiritual and religious beliefs and practices can impact on health behaviours and practices, health outcomes, use of and access to healthcare, and decision-making regarding medical treatment.”

Some examples of the influence it can have include the following (this list is not exhaustive):

• Jehovah’s Witnesses faith requires prohibition of medical procedures involving blood, e.g. blood transfusions.
• Some religions prohibit certain foods, so any treatments must not contain any of these foods, e.g. the Hindu faith does not allow bovine products and the Muslim and Jewish faith prohibit porcine products, which may be in drugs, implants, medical dressings, etc.
• Patients who religiously fast may find adherence to medication and treatment plans difficult or impossible.
• Some religions prohibit abortions and do not permit artificial birth control, e.g. Catholics.
• Some cultures have rituals that are illegal in the UK, such as female genital mutilation (FGM), which conflicts with safeguarding and child protection. Healthcare professionals have a mandatory duty to report cases to the police and/or social care.

Healthcare professionals must consider these influences, impacts and ethics when making decisions. They can face ethical dilemmas where a patient’s safety is at risk due to the care or treatment options conflicting with their culture or beliefs, or they break patient confidentiality because of safeguarding.

Patients have the right to refuse tests or treatments if they conflict with their cultural and religious beliefs, as long as they have the capacity to make the decision and are an adult. However, healthcare providers may need a court order to proceed with the treatment, even without the patient’s consent, if it is in their best interests, if there is a significant risk of harm and even death, a lack of capacity, or if it involves a child. In these cases, patients’ safety and beneficence trump autonomy, but the latter must still be respected as much as possible, and patients should be involved in shared decision-making.

To navigate these diverse perspectives, healthcare professionals should:

• Understand and adhere to legal and ethical frameworks, professional standards, employer policies, procedures and guidance.
• Be aware of the different cultural, spiritual and religious beliefs and their impact and influence on healthcare and individual health and well-being.
• Be aware of the influence of their own beliefs and biases when considering patients’ needs.
• Work in a person-centred way, where the patient is put at the centre of their care and support so they can choose and control how they want it to be.
• Consider if patients are undergoing complementary and alternative medical treatments and traditional healing practices that could affect treatments.
• Work with patients to understand what is important to them, their cultural, spiritual and religious considerations and what they find acceptable regarding diagnostic investigations, proposed treatments and medications.
• Respect the right to refuse medical treatment (including life-sustaining treatment) by a competent adult with capacity, even if it is distressing.
• Refer to clinical ethical committees if there are complex cases with ethical dilemmas for further support and guidance.

Ethical Training for Healthcare Professionals

Healthcare professionals must make informed and ethical decisions, some of which can be extremely difficult, distressing and even life or death choices. They must apply ethical principles to their patients’ situations and balance them when ethical dilemmas, such as conflicts, arise. Therefore, they must have the competence to ensure they provide person-centred and holistic care to patients and treat them with dignity and respect while deciding on the most moral course of action. They must know (this list is not exhaustive):

• About ethical theory, professional standards, local and national policies and relevant laws.
• How to recognise and approach a situation that raises ethical issues.
• The actions to take when facing ethical questions.
• The ethical frameworks and principles that apply to situations.
• What to do if a patient lacks mental capacity.
• The factors to consider when ethical dilemmas, such as conflicts, arise.
• What good practice looks like.

A lack of ethical training and competence can put healthcare professionals and their patients at risk. It can lead to a poor patient experience and outcomes, i.e. not meeting their needs, preferences and beliefs and leaving them out of the decision-making process. It can also cause harm to patients if their care and treatment are not personalised or in their best interests. Healthcare professionals may find themselves on the wrong side of the law or facing civil lawsuits. It can also affect their registration if they make costly mistakes due to negligence.

Healthcare professionals must undergo ethical training appropriate for the setting in which they work and their employer’s and professional body’s requirements. They must also ensure their ethical education is ongoing by undertaking Continuing Professional Development (CPD), which will also be a requirement to maintain registration in their field.

Some of the resources and strategies available to healthcare professionals for ongoing ethical education include:

• Use ethics standards and guidelines – for advice and guidance, for example:
  • The British Medical Association Ethics Guidance – advises on the legal and ethical issues potentially encountered in professional clinical practice. It is for doctors, but other healthcare professionals may also find it useful.
  • HCPC Standards of Conduct, Performance and Ethics – an ethical framework that covers many health and care professions, which registrants must follow.
  • The Institute of Medical Ethics (IME) – has resources on medical ethics and bioethics.
  • UKCEN – has many educational resources for clinical ethics committees, which healthcare professionals could use in their learning.
  • NICE Guidelines – are evidence-based recommendations for health and care in England.
  • Specific professional standards and guidance – healthcare professionals will have specific requirements for their profession, e.g. GMC ethical hub for doctors, GDC standards and guidance for dental workers, NMC Code for nurses, midwives and nursing associates and many others.

• Read scientific and healthcare journals and papers – to gain insights into the latest ethical developments in healthcare, e.g. Journal of Medical Ethics, Sage Journals Clinical Ethics, BMC Medical Ethics, etc.
• Join a clinical ethics committee – to work with others in a multidisciplinary team to support ethical decision-making, which can help healthcare professionals apply what they learn in meetings to their own situations and identify ethical dilemmas they were not previously aware of. They must gain core competencies and skills to become a member, which they can use in their own practice.
• Attend short courses – to boost confidence, knowledge and skills to make ethical decisions. Universities offer courses such as:
  • Imperial College London Applied Clinical Ethics (ACE) Course.
  • The University of Leeds Professional Ethics Courses.
  • NHS England Public Health Ethics Programme.

• Enrol on online CPD courses – to gain knowledge on applicable laws, safeguarding and mental capacity, e.g. Safeguarding Courses, Care Courses, and Mental Health Courses.

Striving for Ethical Excellence

Ethical-decision making is essential in healthcare; not only is it a legal requirement and necessary for professional registration and membership, but it also has many positive impacts on patient care and outcomes, as it:

• Establishes a trusting and respectful relationship between healthcare professionals and their patients, leading to better communication and collaboration and increased confidence in healthcare systems.
• Places a duty on healthcare professionals to not harm their patients and do what is in their best interests, leading to better decisions on care, treatments and interventions.
• Encourages shared decision-making where healthcare professionals and patients work together, helping to provide more personalised and person-centred care to patients that meets their needs, preferences and beliefs.
• Helps patients get the correct care and treatments to improve their well-being so they lead happier and healthier lives. It may also reduce the need for further healthcare and additional burdens on the system.

Healthcare professionals must reflect on their own ethical practices, good or bad, as it can help them cope with distressing quandaries regarding ethical dilemmas and provide them with opportunities to learn lessons to improve patient outcomes.  It also boosts their knowledge, skills, and confidence to become better learners and healthcare professionals.

There may be situations where things could have gone better or incorrect decisions were made. However, mistakes can be costly, so it is essential to avoid them by continuously striving for ethical excellence in healthcare. It helps to make better informed ethical decisions to provide consistent and high-quality patient care to improve their outcomes and healthcare experiences.

Conclusion

Ethics are fundamental in healthcare, especially with the diverse nature and number of patients requiring care and treatments and the various health and social care services and settings within the UK. If healthcare professionals work within ethical guidelines and apply ethical principles when making decisions, it can protect them and their patients.

Working in healthcare is extremely challenging, and those working in the sector can face many ethical dilemmas. They must navigate these issues in line with legal and ethical frameworks and balance them with respect for patient autonomy and beneficence, along with other factors and considerations. However, they do not have to do this alone. Even though the final decision regarding a patient’s care and treatment will rest with them, there is plenty of support for ethical decision-making. Ongoing ethical education can also help them make the best moral choices for patients.

If healthcare professionals effectively balance autonomy and beneficence and approach each patient’s needs with thoughtful decision-making and sensitivity, it can lead to better patient care and improved ethical practice. The aim is to prioritise patient well-being and act in their best interests, even if, at times, they disagree.

Please use the comments section to share experiences, questions, or insights related to healthcare ethics. Use the space to foster a thoughtful and informed discussion.